Basic Shoulder Movement Videos

Audience: Patients Purpose: Exercise videos for those doing shoulder rehabilitation

Preamble

The same exercises or movements can be used with different intentions and to achieve a different goal.  Some possible intentions being:

1. Motion is Lotion - we are moving your shoulder in a manner just to calm down nerves, decrease pain and get that pissed off shoulder happy with moving again.  The amount of weight or resistance is not that important

2. Stress loading - for whatever reason we want to stress your shoulder and shoulder girdle musculature.  You might have some weakness (e.g. prolonged immobility, post surgical) or we wish to increase the capacity of your joint and muscles to withstand load.  Appropriate weight selection, speed of movement and technique is important

3. Motor control - certainly there is some overlap with the previous two intentions mentioned.  But with this intention we might look at trying to change how your muscles work together.  An example, is training both the internal and external rotator cuff during alternating movements.  We are trying to get the cuff to pull the humeral head away from the scapula or just get the muscles happy working together again.  Load or stress is important but so is learning the movement.

Here we go.  A bunch of videos.

Sidelying External Rotation (for training the rotator cuff and the lower trapezius)

http://youtu.be/2aVy6sDVa4c

Scaption (for training the supraspinatus and the posterior cuff during arm elevation)

http://youtu.be/3fRcgp2-nmM

Unilateral "Y" Exercise on Stomach

http://youtu.be/45tT5CsY7ws

 

Unilateral "T" Exercise

http://youtu.be/0ptjYqn0vbE

 

Unilateral External Rotation

http://youtu.be/N7KkQwL51cY

 

Standing External Rotation with tubing (care of www.mikereinold.com)

http://youtu.be/_G0feLqXA0E

 

 

 

Shoulder Impingement Rehabilitation: Part One

Audience: Health Professionals and Patients Source of Information: Paula Ludewig, Ben Kibler, Ann Cools, Rafael Escamilla, Mike Reinold, Kevin Wilks

Disclaimer: The information below really just scratches the surface.  References at the end of post are excellent.  The point of this post is to get people to think more about culprits of dysfunction when it comes to the shoulder rather than just labeling shoulders with victim diagnoses (e.g. bursitis, tears, "tendinitis" - I hate that word - a future post will address my disdain).

Shoulder Impingement is not a diagnosis.  It is a finding and can be both a cause and the result of dysfunction.  Impingement is pretty much what it sounds like - something is getting pinched.  Ever reach into your back seat or reach to put your coat on and feel a sharp pain somewhere around your shoulder (and often down to your elbow).  That is impingement.  Some structure under the shoulder blade is getting pinched and does not like it.  Who likes to get pinched?

I crudely categorize  shoulder impingement into two categories (although they can be split to a greater extent as well) - 1. Internal impingement and 2. External Impingement.

Internal Impingement - what is pinching?

  • rotator cuff muscles (Supraspinatus and Infraspinatus) get pinched against the upper-back (and even the upper front) portion of the Glenoid/Labral complex during shoulder abduction and external rotation.  This is essentially the position of throwing or reaching to put your coat on.
  • less commonly, the subscapularis muscles (an internal rotator cuff muscle) can get pinched between the corocoid process and the lesser tuberosity of the humerus

External Impingement - what is pinching?

  • pinching of the rotator cuff tendons or long head of the biceps brachii on any part of the coracoacromial arch (i.e. the underside of the front of the shoulder blade).  This arch consists of the coracoacromial ligament, the acromial undersurface and the undersurface of the AC joint.

The aim of treatment - Stop the pinching stupid.

The end goal of treatment is simple.  Get the surfaces that are pinching each other out of each other's way.  When my 3 year old pushes over my 10 month old I don't leave them beside each other.   With impingement treatment we are trying to make space -   Space can be made in two ways:

1. Get the arm bone out of the way (some will call this joint centration) by optimizing rotator cuff function.

2. Get the shoulder blade out of the way.  We will try to put the shoulder blade in an optimal position.

How do we make space?

I typically use a lot of manual therapy.  An extensive amount of my modified Active Release Technique, gentle trigger point holds, contract-relax, PIR, spine manipulation, A-P mobilizations etc.  I tend to treat any structure that can influence the shoulder and less scientifically, "feels not normal".  Because that is a lot of the  magic of manual therapy - we do a subjective evaluation of tissue texture, "vitality", robustness, springiness, ropeyness, "adhesions" etc and work those areas.  I will treat all "faulty" tissue that attaches to the shoulder, the neck and the back.  Ultimately, I believe that I am influencing the nervous system to modulate pain and change muscle recruitment.

One caveat, I tend to avoid stretching the front of the shoulder.  I kept seeing weight lifters (i.e. bench pressers) with internal impingement but they thought they were protected because of stretching the crap out of the front their shoulder and then busting out a deep bench press.  Avoid this please.  This may cause anterior laxity which then allows the the humeral head to translate into a pinching position.

But Manual Therapy is just the start:

In order to make long lasting change we need to change how the shoulder complex functions.  It is through rehabilitation exercises (both supervised/corrected and at  home) that we can essentially teach the shoulder and spine musculature to again work like the good team that they are and stop the pinching.  Because it is often the loss of teamwork that is the problem.  A shoulder might have an incredible amount of strength but certain positions or movements cause an equally incredible amount of pain.  Lots of strength does not equal a healthy shoulder.  What is mostly likely happening is that something is wrong with how the body moves and optimal body movement is a result of good teamwork by the muscles.

Below is a quick overview of some components of the rehabilitation regime.  Part two of the post will delve a great deal into the science and research behind appropriate exercise prescription.

Overview of elements that might be incorporated (if needed)

1. Check and train spine stability - people should be doing lower spine exercises so why not introduce McGill's big three or some other program for the spine that you like.

2. Stretch pectoralis minor (this might lead to decreases in anterior tilting of scapula to make more space underneath and has been shown to be associated with improvements in pain)

3. Check and treat deep neck flexor inhibition (perhaps the patient is using the superficial neck muscles excessively which then anteriorly rotates the scapula or inhibits movement of the clavicular - again this can decrease space.  **Please note, I don' t think there is any research (despite the almost universal acceptance of the upper crossed syndrome) on this but it is not unreasonable to  think that alterations in how the neck moves can negatively affect how the shoulder blade moves.

4. Teach the external and internal rotator cuff muscles to "play catch" with one another.  One theory on dysfunction is that the rotator cuff no longer works as a team and then no longer centres the arm bone under the shoulder blade.  Working the arm in external and then internal ranges can facilitate these muscles.  Follow this with...

5. External rotator cuff strengthening at neutral first and then all ranges of elevation.

6. Posterior capsule stretching (e.g. sleeper stretch, cross body adduction).

7. Serratus anterior strengthening

8. Scapular positioning exercises (learning how to move the scapula into different positions - up, down, back, forward)

9. Teach diaphragmatic breathing (Why not, everything is connected)

A future post will explore in much greater detail shoulder rehabilitation exercises.  This next post will focus much on the work of Ann Cools, Mike Reinold (www.mikereinold.com), Paula Ludewig and Rafael Escamilla.  I take no ownership of the research - I am just an early adopter and respect the science and thought behind their exercise prescriptions.

UPDATE: As goes with the internet there is a tonne of redundancy.  Please see the following link from Mike Reinold who made a great post on impingement way back last year and way before me.  Dr Reinold is also involved in the research attempting to understand shoulder pathology so it is nice and prudent to go to a primary source. http://www.mikereinold.com/2010/11/shoulder-impingement-3-keys-to.html

References

1. Ludewig PM, Braman JP. Shoulder impingement: biomechanical considerations in rehabilitation. Man Ther. 2011 Feb;16(1):33-9.

2. Cools AM, Cambier D, Witvrouw EE.Screening the athlete's shoulder for impingement symptoms: a clinical reasoning algorithm for early detection of shoulder pathology. Br J Sports Med. 2008 Aug;42(8):628-35. Epub 2008 Jun 3. Review

3. Reinold MM, Escamilla RF, Wilk KE. Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature. J Orthop Sports Phys Ther. 2009 Feb;39(2):105-17. Review.

4. Kibler WB, Ludewig PM, McClure P, Uhl TL, Sciascia A.Scapular Summit 2009: introduction. July 16, 2009, Lexington, Kentucky. J Orthop Sports Phys Ther. 2009 Nov;39(11):A1-A13. Review.

5. Escamilla RF, Yamashiro K, Paulos L, Andrews JR.Shoulder muscle activity and function in common shoulder rehabilitation exercises. Sports Med. 2009;39(8):663-85. Review.

Shoulder Rehabilitation: Minimizing the Upper Trapezius to Serratus Anterior Ratio

Audience: Therapists

Purpose: I like the idea of quantifying the "dosage" of an exercise.  We can do this with EMG and this post will be part of a larger theme that catalogues the EMG amplitude of various shoulder rehabilitation exercises.  Further, it will also try to justify a number of exercises for their ability to avoid negative loading on the shoulder and promote a possibly optimal way of working the shoulder.

Caveat:  This review only looks at a few papers addressing the Upper Traps (UT) to Serratus Anterior (SA) ratio.  Other exercises must obviously be incorporated into a rehab program.

Exercises to maximize the Serratus Anterior (SA) to Upper Trapezius (UT) Ratio

To simplify: SA = good, UT = bad.  Basically, activation of the SA moves the scapula out of the way of the humerus while too much or too early activation of the UT tends to

anteriorly tilt the scapula and decrease the space for humeral movement.  Ann Cools has done extensive work in this area.  Here is a taste of her findings and recommendations.  You may want to consider using the exercises when you have a little scapular dyskinesis on your hands - you may see some medial border prominence of the scap, some winging during arm elevation and the scap can get a little jiggy with arm raising and lowering.

Three exercises were selected as exercises with a low UT/LT ratio:

  • side-lying external rotation,
  • side-lying forward flexion, and
  • prone horizontal abduction with external rotation.

Three exercises were selected for minimizing the UT/LT ratio:

  • side-lying forward flexion
  • side-lying external rotation and
  • horizontal abduction with external rotation

The authors conclude that no exercise satisfied their criteria for optimally minimizing the UT:SA Ratio.  But honourable mention was given to forward flexion and scaption with External Rotation.  We therefore have to look to other research to find the best exercise for this ratio - that exercise would be the Push Up Plus which demonstrates a ratio less than 20% for the "plus" portion of the push up and less than 50% for the push up portion of the push up.  Serratus Anterior activity waltzes in at more than 120% for the plus portion and greater than 80% for the push up portion.  Upper trap activity is between 20% for the push up portion and around 9% for the plus phase.  See Ludewig (2004) for the full paper

Some Raw Data

I have bastardized a table from the Supplementary Data of the Ann Cools article.  The following table shows the EMG activity (expressed as a percent of maximum for the Lower Traps, Middle Traps, Upper Traps and Serratus Anterior).  For simplicity I have only included the isometric portion of the exercise. The original article also looked at the concentric and eccentric phases.  Also in the chart is the Ratio of the above musculature to the Upper Trapezius.  Remember, the ideal is be lower.  Suggesting less Upper Trap activity and more of something else.

Table 1: EMG and Ratio Activity during various Rehab exercises (modified from Cools et al 2007)

EMG - % of MVC* Ratios
Exercise UT MT LT SA UT/LT UT/MT UT/SA
Prone shoulder abduction 50 78.4 76.7 14 75 71 597
Forward flexion 38 26.5 29.5 95.2 250 236 53
Forward flexion in side-lying position 8.6 35.5 63.7 34 16 27 50
High row 7.3 17.3 17.5 28.6 62 51 50
Horizontal abduction 33.7 63.8 50.3 17.3 77 60 339
Horizontal abduction with external rotation 43.7 78.2 79.2 15.5 65 65 467
Low row (1) 19.5 30.4 26.2 35.1 120 76 108
Low row (2) 21.6 31.9 20.3 19.9 162 77 206
Prone extension 15.9 30.1 30.9 34.7 82 62 84
Rowing in sitting 31.4 41.6 29.8 12.1 122 105 458
Scaption with external rotation 44.9 31.7 32.3 101.7 273 246 51
Side-lying external rotation 5.54 18.2 51.1 9.8 14 39 92

The next table describes all of the exercises.

Table 2: Exercise Description

Exercise Description
Prone shoulder abduction Subject prone with the shoulder in neutral position; subject performs shoulder abduction abduction to 90° with external rotation in a horizontal plane
Forward flexion Subject standing with shoulder in neutral position; subject performs maximal forward flexion in a sagittal plane
Forward flexion in side-lying position Subject in side-lying position, shoulder in neutral position; subject performs forward side-lying position flexion in a horizontal plane to 135°
High row Subject standing in front of vertical pulley apparatus with the shoulders in135° forward flexion; subject performs an extension with the shoulders until neutral
Horizontal abduction Subject prone with the shoulders resting in 90° forward flexion; subject performs horizontal abduction to horizontal position
Horizontal abduction with external rotation Subject prone with the shoulders resting in 90° forward flexion; subject performs horizontal abduction to horizontal position, with an additional external rotation of the shoulder
Low row (1) Subject standing in front of pulley apparatus, shoulders in 45° forward flexion an
Low row (2) Subject standing in front of pulley apparatus, shoulders in 45° forward flexion and neutral rotation; subject performs extension with the elbows flexed
Prone extension Subject prone with the shoulders resting in 90° forward flexion; subject performs extension to neutral position with the shoulder in neutral rotational
Rowing in sitting Subject sitting in front of pulley apparatus with the shoulders in 90° forward flexion;position with 2 handles subject performs an extension movement with the elbows flexed and in the horizontal
Scaption with external rotation Subject sitting with the arms at the side; subject performs maximal elevation of the arms rotation in the plane of the scapula (30° anterior of the frontal plane)
Side-lying external rotation Subject side-lying with the shoulder in neutral position and the elbow flexed 90°; subject rotation performs external rotation of the shoulder (with towel between trunk and elbow to avoid compensatory movements)

WHY IS THIS RELEVANT?

I think this paper tells us that these are not the exercises that we should be doing if we think that the ratio between UT and the SA is the biggest problem. When we look at the EMG values and not just the ratios we can see that few of the exercises investigated appropriately challenge the SA with the exception of Forward Flexion and Scaption.  Fortunately, they also have relatively good UT:SA ratios (please note, when performed dynamically the ratio is higher, in other words worse for the shoulder).   If we look at previous research by Paula Ludewig who investigated Push Up Plus variations we learn that sticking with the Push Up Plus is still the ideal exercise to train the SA while minimizing Upper Traps.

Do Push Up Plus Exercises for the best UT:SA Ratio

As for the push up plus and its varations (Standard Push Up Plus (SPP), Knee Pushup Plus (KPP) and Wall Pushup Plus) look at the Serratus EMG activity and the associated ratios in the following modified charts.

The chart to the left shows eccentric (blue) and concentric (red) EMG activity during the non "plus" portion of the push up plus.  The "plus" portion is 20-40% MVC higher.  This graph shows that the Push Up Plus activates the Serratus between 40-80% of its maximum (depending on type of movement).  The Plus portion achieves values close to 120% of maximum.  Kneeling push up plus (KPP) and Wall Pushup Plus (WPP) tend to have less activity.

When we look at the Upper Trapezius to Serratus Anterior ratio we find the lowest ratios occur with the Standard Push Up Plus.  Showing less than 50% for both concentric and eccentric portions of the push up  activity (non plus phase) and less than 20% ratio during the "plus" phases of the activity (not in the chart) as I wanted to show the worst case scenario.   Note how the wall push up starts to have a lot more Trap activity and therefore it throws the UT:SA ratio way to high for it to be ideal.  Upper trap activity typically reaches between 15 and 25% during the eccentric portion of the pushup and between 6-12% during the eccentric portion of the "plus" phase of the push up plus.

Bottom Line:  The standard push up and standard push up plus demonstrate the highest levels of Serratus Anterior EMG activation as well as the lowest ratio the UT:SA activity. The wall push up plus should be avoided and it may even lead to impingement.

Further References

Reinold MM, Escamilla RF, Wilk KE. Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature. J Orthop Sports Phys Ther. 2009 Feb;39(2):105-17. Review.

Kibler WB, Ludewig PM, McClure P, Uhl TL, Sciascia A.Scapular Summit 2009: introduction. July 16, 2009, Lexington, Kentucky. J Orthop Sports Phys Ther. 2009 Nov;39(11):A1-A13. Review.

Escamilla RF, Yamashiro K, Paulos L, Andrews JR.Shoulder muscle activity and function in common shoulder rehabilitation exercises. Sports Med. 2009;39(8):663-85. Review.

Ludewig PM, Hoff MS, Osowski EE, Meschke SA, Rundquist PJ Relative balance of serratus anterior and upper trapezius muscle activity during push-up exercises. Am J Sports Med. 2004 Mar;32(2):484-93

Cools AM, Dewitte V, Lanszweert F, Notebaert D, Roets A, Soetens B, Cagnie B, Witvrouw EE.Rehabilitation of scapular muscle balance: which exercises to prescribe? Am J Sports Med. 2007 Oct;35(10):1744-51. Epub 2007 Jul 2.

Raw Data

Scapular Retraction/Protraction Exercise Sheet

Attached is a simple one page exercise sheet to train the lower/mid trapezius (scapular retraction) and the serratus anterior.  The assumption is that these exercises, along with other training and physiotherapy (ART etc), will position the shoulder blade in a better position.  Ideally, avoiding forward tilt and a position that may be related to impingement. Below is the pdf file:

thebodymechanic shoulder retraction basic

Adios,

Greg Lehman